DAVID GARCIA
Subscriber on policy B05M000394
Claims
2
Attributed to this person
Charged
1,686.00
Total submitted
Denied
0.00
1 denied claims
Patient responsibility
565.50
Reported on the 835
Patient responsibility is the amount reported on the 835 as assigned to the patient — deductible, coinsurance or copay. It is not proof that the provider billed the member, that the member owes it, or that it was collected, and it is kept separate from denied amounts throughout.
Who this is
| Field | Value |
|---|---|
| Name | DAVID GARCIA |
| Role on the policy | Subscriber |
| Policy | B05M000394 |
| Date of birth | 22 Apr 1967 |
| Plan | PLATINUM PPO |
| Covered from | 1 Jan 2024 |
| Covered to | open |
Patient responsibility reported on the 835
| Reason | Adjustments | Amount reported |
|---|---|---|
| CARC 50 · Other | 1 | 565.50 |
| Total | 565.50 |
Care and denials
| Claim | Service | Charged | Payer | Outcome | Denied |
|---|---|---|---|---|---|
| CLM0001682 | 15 Jun 2026 | 816.00 | NORTHSTAR MUTUAL | Not denied | — |
| CLM0001681 | 11 Jan 2024 | 870.00 | NORTHSTAR MUTUAL | CARC 50 · MEDICAL_NECESSITY | 0.00 |